Student of Concern
Referral Form
This form allows you to express concerns related to a particular AAMU student and is submitted directly to the Office
of Health & Counseling Services located at 4011 Meridian Street, 35762. The Behavioral Intervention Team facilitates
communication, assists in developing strategic interventions and coordinates management of ongoing or recurring
problems. The ultimate goal is to prevent conflicts and high-risk behaviors from escalating into emergencies. All
reports will be handled in a confidential manner whenever possible. Every precaution will be taken to maintain the
privacy of those who make a referral, when requested.
Please be aware that this form is reviewed during normal business hours. It is not monitored after hours, on weekends or
on University holidays. AAMU Department of Public Safety is available to respond to immediate concerns 24 hours a day,
365 days a year. If you have immediate concerns about the health or safety of a student, or of the AAMU community
because of a student, please call AAMU Department of Public Safety at 256-372-5555. If there is an active emergency,
dial 911 immediately!
Person expressing concern:
Relationship to student:
Your email address:
Your phone number:
Would you be willing to talk with a member of the Behavioral Intervention Team, should they have questions? Y or N
If you are aware of anyone else who may have information that would assist the team in assessing the behavior or
concern, please provide their information below:
Additional contact name:
Additional contact number and/or email:
Student Name:
A#:
Student phone:
Student email:
Student classification:
Student residence:
Nature of concern:
 Academic
For example:
 Significant decline in academic performance
 Excessive absences from class
 Failure to turn in assignments
 Student has stated (verbally or written) that she/he is concerned with
academic performance
 Numerous requests for allowances or accommodations in regards to
assignments/attendance, etc.
 Behavioral
For example:
 Disruptive behavior
 Disturbing behavior
 Sudden change in mood or demeanor
 Concerning use of alcohol or drugs
 Self harm behaviors (cutting, scratching, etc.)
 Potentially risky behaviors (restricted eating, excessive exercising,
binging/purging, misuse of medications, etc.)
 Expressions/thoughts of wanting to harm self or others
 Social/Emotional
For example:
 Loss of friend or family member
 Relationship issues
 Sexual assault or domestic violence
 Physical or sexual abuse
 Depressed state or anxious beyond what seems normal
 Thoughts or threats of suicide
 Other (please explain):
Please describe the behavior(s) or situation that led you to be concerned about the student. Include date & time (if
known), how long you have witnessed the behavior(s) and any specific threat and/or upcoming event, meeting time, or
class for which you are particularly concerned:
Please provide any additional information that might help us identify the student (i.e. physical characteristics (tattoos,
piercings), campus location, place(s) frequented, license plate number/vehicle description, etc.):